Sports medicine focused attention on physical fitness
The specialty has had an impact on society beyond the playing field, thanks to some visionary leaders.
Sports medicine started with a bang in the Northeast at the beginning of the 20th century when E.A. Darling of Harvard published an article in 1899 in the Boston Medical and Surgical Journal called “The Effects of Training,” which involved a study of the fitness of the Harvard crews. It is widely believed that this paper initiated the modern studies of the effects of training.
Immediately thereafter, the “Rules of Playing” by Edwin Nichols, MD, in 1905, showed the rate of injury and fatality in American football. Then, in 1909, Nichols wrote a second article detailing a great reduction in fatal football injuries following rule changes brought about by Walter Camp and the National Collegiate Athletic Association (NCAA) committee formed for that purpose.
One 19th century professor, however, is in many ways responsible for influencing these early sports medicine endeavors. In 1854, Edward Hitchcock, MD, an instructor in physical education and hygiene at Amherst College in Amherst, Mass., wrote about education principles for gymnastics, baseball, basketball and other sports. During his tenure, he published many articles on a variety of subjects in athletics and medicine. Consequently, he is known as the “father of physical education” in America and regarded as the first team physician in this country.
It wasn’t until Mel Stevens, MD, at Yale Medical School, who became a football coach at Yale and president of the American College of Football Coaches Association in 1932, that the profession recognized its first sports medicine physician. After chairing the coaches association’s committee on the study of football injuries, he moved to New York in 1934, where he became coach of the New York University football team and an orthopedic staff member at the Ruptured and Crippled Hospital in New York.
Then, in 1938, Augustus Thorndike, MD, of Harvard University, laid the groundwork for sports injury management over the next few decades with his textbook, Athletic Injuries: Prevention, Diagnosis and Treatment. This was the first general American text of sports medicine, and it still serves as a model today. At the same university just two years later, surgeon Thomas B. Quigley, MD, joined the Harvard Athletic Program and authored the Athlete’s Bill of Rights. In 1960 it was adopted in an official capacity by the then-recently-formed American Medical Association (AMA) Committee on the Medical Aspects of Sports. This bill of rights established requirements for good athletic medical care, and always maintained as top priority the rights of the athletes.
A bold new step at mid-century
The formal organization and recognition of sports medicine as a bona fide subspecialty didn’t start until the 1950s. Across the country, college professors in physiology and chemistry and researchers with a focus on athletic injury nurtured a growing interest in muscle physiology, exercise and fitness. To enhance communication among themselves, they organized the American College of Sports Medicine in 1954, and physicians joined the organization for the purposes of learning and networking. In 1969, this organization began publishing the journal, Medicine and Science in Sports and Exercise. This journal served their purposes quite well, but it did not serve the purposes of the clinician in sports medicine.
In the early 1950s, the National Athletic Trainers Association (NATA) was founded to unite trainers of college and professional teams. The growth of NATA from a small, inexperienced organization to the comprehensive association it is today, however, did not happen overnight. I attended one of the first annual meetings of the NATA, held in 1955 in Miami, which attracted only approximately 50 trainers. I attended each annual meeting from 1955 until the early 1970s in an effort to forge associations with my colleagues and create a liaison between the orthopedic surgeons in the American Orthopaedic Society for Sports Medicine (AOSSM) and athletic trainers. During the early years of sports medicine, it was certainly the athletic trainers and the orthopedists who worked most closely together in the “trenches.” At the time of the NATA meeting in Miami in 1955, NATA voted to pursue developing a core curriculum for training/education, and voted to affiliate with organized medicine to help promote a more formalized curriculum. NATA eventually became an affiliate of the AMA in the early 1960s with guidance and support of Fred V. Hein, PhD, director of the department of health education with the AMA. The NATA now publishes its own scientific journal, The Journal of Athletic Training, as well as an excellent newsletter. A recent annual NATA meeting I attended in Denver brought together nearly 10,000 athletic trainers.
The medical advisory committee
Another turning point in the evolution of sports medicine that occurred during the 1950s was the NCAA’s request to the AMA Board of Trustees to look into the possibility of developing a medical advisory committee. From this initiative evolved the AMA Committee on the Medical Aspects of Sports (MAS). In December 1960, the AMA-MAS presented its first national conference on the medical aspects of sports in conjunction with the clinical convention of the AMA with a 1½-day meeting of presentations and conferences with other sports organizations. This meeting continued each year during the AMA’s clinical convention until the committee’s dissolution around 1975.
Hein, who served as committee secretary, guided the function and activities of the AMA-MAS. At the opening of the general session of this meeting in 1966, Hein stated: “The [AMA-MAS] was founded during a period when sports were becoming a basic and integral part of the American culture. The new acceptance and dignity that sports and athletics were acquiring helped the committee to become a catalyst in improving their health and safety supervision. The tangible accomplishments of the committee were important in themselves, but an intangible — the respected position ‘sports medicine’ has acquired within the medical profession — is even more significant. The committee has been aided and abetted in these achievements by a growing number of other agencies and organizations interested in sports medicine. All of these groups should unite to encourage widespread participation in sports and to help bring the benefits of sound health and safety supervision to as many individuals as possible.”
The activities of this committee started at the grassroots level and continued all the way to the top. They carried out and fostered research relative to head protection, and they successfully advocated for the elimination of spearing in contact sports. They stimulated the continued support of research in helmet design. The committee also produced publications devoted to the health care of the athlete, including Safeguarding the Health of the Athlete, Tips on Athletic Training, A Guide for Medical Evaluation of Candidates for School Sports, A First-Aid Chart for Athletic Injuries, The Bill of Rights and the College Athlete and Protecting the Health of the High School Athlete, among others.
Working with the Olympians
Under the encouragement of Don B. Slocumb, MD, and Hein, the AMA-MAS made a concerted effort to establish a better medical relationship with the U.S. Olympic Committee. Until this time, Daniel F. Hanley, MD, of Bowden College in Orono, Maine had served as the primary Olympic team physician and was doing an excellent job and continued thereafter. However, the Organization of Sports Medicine wanted to get deeper insight into the care of Olympic athletes, and used the excuse of potential risks to athletes due to Mexico City’s altitude as a way to getting more involved in the Olympic events.
Meritt H. Styles, MD, of Seattle and of “altitude medicine” fame, related the development of this committee in preparation for Mexico City. Styles had attended many alpine ski competitions in an official capacity, at elevations up to 12,000 feet, and could not recall having heard even the question of altitude up to the time of the Mexico City Olympics. However, the press made altitude an issue and brought more organized medical involvement into the U.S. Olympic committee. As Styles stated, the principal concern with respect to the competition in Mexico City, would probably be one of enteritis.
A great unrecognized force in sports medicine in the 1950s was the team physician at the high-school level. This was especially true in the field of orthopedics. In the Southeast, this movement gained so much momentum that it became recognized by the Medical Association of Georgia (MAG) as one of the greatest public relations issues they had ever seen. The MAG thereby asked Kenny Howard, the trainer at Auburn University, and I to run a conference on the Medical Aspects of Sports in Columbus, Ga., in 1960. We did not know what we were doing, and we had no model to go by. That was fortunate, however. We ended up having dentists, cardiologists, general surgeons, high-school superintendents and high-school coaches all on the program.
A voice for the profession
Our most fortunate occurrence was looking for someone to speak on rules and regulations, which we believed would be a major area for the prevention of injures. In our search, we gained direction from the executive offices of the National Federation of State High School Athletic Associations in Chicago, due in part because the ongoing president of the organization was Sam Burke of Thomaston, Ga., who lived just 60-odd miles away from us. It was also fortunate for us that Burke was a highly visible person in the High School Athletic Association and did not mind speaking passionately on whatever he thought.
Gaining his support and endorsement probably resulted in the greatest leap forward that sports medicine has made before or since. Preventive measures, change of rules, protective equipment and other protective measures were introduced and established in just 12 to 18 months to cover the entire United States. For instance, thanks to Burke’s advocacy efforts, nearly every trainer and boxer in the country soon became aware that the mouthpieces (worn while participating in boxing) helped prevent concussion. Prior to the MAG conference, I was not familiar with any high school or college athletic program that used mouthpieces, except for the report from Victor Della Giustina, DDS, of the Public Health Department in Augusta, Ga., who volunteered his services to the Richmond Academy (a high school in Augusta) because of his interest in dental injuries.
Following his presentation on the benefits of mouthpiece use, which demonstrated a decrease in tooth loss, savings on dental bills and an incidental decrease in concussions, Burke made the use of mouthpieces mandatory at the high school level in Georgia the following year, and for the entire United States the year after that. Mouthpieces could be easily made by an internist or the wife of an orthopedist, or whomever was interested by taking wax impressions of the teeth, and pouring these and making molds in the home oven and thereby making the plastic mouthpieces.
Demonstrating a tangible benefit
Wisconsin was the only state self-insured for school injures, and thus, was the only state in which statistics could be obtained relative to the dental benefits. As I recall, the cost of dental injuries was reduced 75% the first year the mandatory mouthpiece rule was in place, and each year thereafter it continued to drop.
So, as is frequently the case, it is not who describes a technique or benefit the first time, but rather who is in the right place at the right time to make the presentation of the technique or benefit to the most people who has the most widespread and long-lasting effect on the practices of others. The mouthpiece was not an easy sell. It wasn’t until those youngsters grew up and went to college that it gained widespread use in college. Subsequently, it went on to the pros. This roundabout path to acceptance has been the way with most all of the changes in rules, regulations and injury prevention equipment throughout our history.
I further remember when Creighton Hale, PhD, head of Little League Baseball, instituted the requirement of batters wearing helmets while at the plate. At the time, the pros laughed! But now, you never see a professional step up to the plate without wearing a helmet with the temporal guard. So, the youngsters grew up and they rightfully wanted the protection, and there was nothing “sissy” about it. Little League Baseball was also responsible for instituting the substitution of rubber cleats for the traditional metal cleats on baseball shoes.
Recognizing the visionaries
So, to me at the time, it was Hein, the AMA, Burke, and the National Federation of State High School Athletic Associations which worked together so closely and which instituted the changes to make them become effective immediately. The mouthpiece was just one good example. Burke made compliance very easy: If a boy didn’t wear his mouthpiece, the team was penalized 15 yards, and the athlete was thrown out of the game.
In other initiatives by the aforementioned parties, the wet-and-dry bulb was used for determining whether or not the humidity and temperature were too high for safe competition, and if they were, the game was cancelled. A physician was required to be present on the sidelines, or immediately available, at all games. Water and other fluids, which had been severely discouraged for athletes in the prior years, now became almost mandatory, and some commercial products gained a great market. It is nearly impossible to see a television view of the sidelines without seeing a coach or player drinking from a lively colored cup labeled “Gatorade.” Athletes no longer had to merely wet their mouths with the water and then spit it out. They were encouraged to drink their water and replace their fluids at the time of sports participation. This undoubtedly saved many lives. The list of such changes, benefits, and advancements grew so large, and the story behind their occurrence is usually so interesting that it would take a whole book just to cover them. So again, the National Federation of State High School Athletic Associations became the perfect liaison and partner of the AMA Committee on the Medical Aspects of Sports and the recommendations of this body relative to injuries and illnesses.
Education via the AAOS
In 1964 or 1965, the American Academy of Orthopaedic Surgeons (AAOS) instituted postgraduate education in the form of instructional courses. At first, the AAOS included the subject of trauma and the subject of sports medicine. Thereafter, it spread to many other divisions of orthopedics. Many courses were presented around the United States.
In sports medicine, there were three such three-day courses per year held throughout the country, which covered various aspects of sports medicine such as general sports medicine, the knee, the shoulder, etc. These courses continued at about three per year for more than 10 years and created a tremendous development of sports medicine and a learning experience on the part of the faculty as well as that of the attendees. The three annual sports medicine courses produced approximately 60% to 70% of the revenue of the entire AAOS Division of Continuing Education.
It was these courses, with about 300 attendees at each course, that produced the true forces in sports medicine that spread out all over the United States and to many foreign countries. The challenge to presenters was tremendous. A presenter would have about a two-year advance notice relative to his subject. During that time, it was up to him to come up with advances, new information, and controversies. Fulfilling these challenges resulted in tremendous advancement of our knowledge relative to sports, and relative to sports-related injuries and illnesses.
Introducing the AOSSM
Early on, it was obvious that the tremendous interest and participation in sports medicine would quickly grow to a point of being beyond what could be handled by an appointed committee. Thus, from the cadre of these courses came the development of the American Orthopaedic Society for Sports Medicine (AOSSM) in 1972 as an affiliate of the AAOS. The AOSSM has continued as a highly visible scientific organization promoting all aspects of the field of sports medicine, and has now grown to several thousand members. In addition, sports medicine needed a peer-review journal for publications of many sports medicine subjects related specifically to orthopedics and surgery. The American Journal of Sports Medicine was born in 1972 and has blossomed to become an outstanding official publication of the AOSSM, led by Chief Medical Editor Bob Leach, MD, of Boston, and boasting approximately 10,000 subscriptions.
Likewise, physical therapists developed a special suborganization of the American Physical Therapy Association called the Sports Physical Therapy Section, and also began a publication, The Journal of Orthopaedic and Sports Physical Therapy.
In 1968, orthopedic fellowships and residencies devoted to sports medicine were initiated. Around 1980, primary care (family physician) fellowships were initiated. This concept has thrived in popularity and has been incorporated in many of the orthopedic sports medicine centers. These family physicians have organized themselves into the American Medical Society for Sports Medicine as an adjunct to the American Society of Family Practitioners. They have developed annual programs and often align their programs with the AOSSM annual programs.
Continued growth even today
Sports medicine continues to grow at a fierce pace with regard to basic science progress, clinical progress and education, and sports medicine coverage. Almost every college or professional team today has a dedicated orthopedist, a dedicated family practitioner (often-termed primary care sports medicine physician) and a certified athletic trainer. In addition, many teams receive coverage or service by a physical therapist dedicated to sports.
In some ways, the term “sports” and sports-related phraseology have become almost too popular today. Advertisers use it to refer to shoes, clothing, drinks (fluids) and to most anything else anyone can dream that is even remotely related to health and fitness. Despite this small drawback, the benefit of our widespread embrace of sports medicine today is increased awareness of the importance of attaining and maintaining physical fitness in every age group.
Jack C. Hughston, MD, is an orthopedic surgeon and is founder and president of the Hughston Sports Medicine Foundation Inc. in Columbus, Ga.